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Cultural Differences in Depression

NTRODUCTION
According to the United Nations Immigration Fund (2017), it is currently estimated that 244 million people or 3.3% of the world’s population live outside their country of origin. Although stressful and challenging moving has been a part of many families lives. This process has made an impact on individuals and the families who encounter such changes.  The undeniable truth is that worldwide people are experiencing change and the effects on mental health have taken reached far into different races, ethnicities, and cultures.  Depression has been found to be one of the most common disorders people experience today, affecting approximately 300 million people worldwide (McLoughlin, 2002).  As people from different places unite and combine their background differences and cultural narratives, families and social structures change. Cultural effects on mental health specifically on depression have proven to be significantly necessary for the understanding, detection, diagnosing and treatment of individuals with the illness.
Problem Statement
Depression is one of the most debilitating disorders (Kalibatseva & Leong, 2014), and due to the size of the problem and its prevalence in the minority communities, precise assessment of depression for cross-cultural individuals is critical (Sashidharan, Pawlow, Pettibone,  2012). Since the definition and perception of mental health differ depending on who you ask, the factors that influence it can be broad, and hard to decipher.  Clinical observations suggest that the symptoms of any mental health disorder such as anxiety and depression overlap and are hard to differentiate (Wang et al. 2016). According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000), a person who is experiencing symptoms of depression may describe having depressed mood, loss of interest in activities that were formerly pleasurable, and feeling of hopelessness. Additionally, there may be changes in eating habits,  disruption in sleep, and decreased energy, which may result in thoughts, planning, or attempts of suicide.  As stated in Cardemil, Kim, Pinedo, and Miller, (2005) depression is a mental disorder that affects individuals of all racial, ethnic, and socioeconomic backgrounds. Depression does not discriminate. In fact, depression is described as one of the most prevalent mental health disorder in western societies.
In the past, many thought that depression was a mental disorder affecting people mainly in affluent countries and not so prevalent in underdeveloped poor countries. Depression is a severe recurring disorder that affects life quality, health, and mortality (Bromet et al., 2011).  Depression was also something that many people thought only affected the person who had the disorder and not anyone else. Most recently though research has shown that the effects of depression extend far more than the individual, it also affects the people around them. When a person suffers from depression, it affects the ones who are around them in different ways as they have to deal with varying moods, behaviors and attitudes.  It is difficult to love and care for someone who does not love or care for themselves.
Project Purpose
Mental health has been researched among various racial, ethnic, and cultural groups.  Acculturative stress, social self-efficacy, and acculturation family distancing have been shown to be among the most prevalent factors affecting depression. It has also been documented that there is a strong relationship between health suppression and cultural background (Soto et al. 2011).  The differences are mainly due to the variation of cultural standards and the cultural values people hold.  For example, depression is experienced differently in Eastern and Western cultures. People from the East hold different cultural values than those from the West. For instance, Sashidharan et al. 2015 discussed the experience of worry among different cultural groups.  They mentioned that although worry was present in all individuals, those from nonwestern cultures were more likely to experience biological instead of cognitive symptoms. The increasing drive in considering culture as well as ethnic factors in mental health services can be used to identify gaps and deficiencies in treatment, and suggestions for improvements to the overall services.
The understanding of the cultural-specific factors that directly affect a patients history and their behaviors has become essential for mental health professionals to appropriately adjust their approach to fit the needs of a diverse population.  This integrative literature review on cultural factors that affect depression analyzed Twenty-four quantitative studies investigating various non-Western, and Western cultural groups were analyzed by categorizing depressed and non-depressed participants into similar groups.  The purpose of the integrative literature review is to present studies and research conducted to quantify and substantiate the data found in supporting the relationship between cultural differences within a group and depression. It also reviews the effect cultural acculturation, self-efficacy and coping styles influence the way patients to manage, seek, and receive treatment for the illness.
LITERATURE REVIEW
The World Health Organization (2004) reports about 121 million people worldwide suffer from depression.  Bromet et al. (2011) presented interviews with people in different countries varying from richest to poorest and found that in fact, depression differed across countries, but affected everyone in some way.  Research results show over and over that depression is a significant public-health concern across all regions of the world and is strongly linked to social and cultural conditions.  For example, stressful events either positive or negative can be experienced differently by different people.  These events can trigger feelings of helplessness or hopelessness in some and may lead to depression in others.  Depression interferes with daily living and makes it hard to do the normal things you usually do. Factors such as genes, environment, and culture affect and influence the how a person experiences depression.
Depression is a major mental disorder affecting many people today, and it is manifested in ways that include psychological and physical symptoms. Although it may be viewed as someone being sad, or not having the desire to associate with society, it is far deeper than that.  Unlike commonly thought, depression can occur in someone who is not feeling sadness at all. Instead, they feel irritable or have no interest in the things they are accustomed to doing.  Riaz et al., (2014), states that the way in which people perceive themselves plays a vital role in a person’s psychological well-being, physical health, and interpersonal relationships and these abilities control their thoughts, feelings, and behavior.
Depression Across Cultures
While there is no determining factor in identifying the prevalence of depression across culture, available data show the high rates of depression among different cultural and ethnic groups around the world.  According to the World Health Organization (2004),depression is now a health issue faced by people worldwide,ranging from adolescents to older college students. A study by (Brown et al. 2007) found that the occurrence of depression was 10 to 85%, with a weighted mean prevalence of 30.6% in case of university students all over the world (Dzokoto, 2010).
Depression prevalence is higher among college students compared to the general population (Carrera & Wei, 2014). It is mainly due to the transitioning period college students face and the challenges that come with having to make important decisions, making the social and personal pressures even worse.  Previous studies of depression treatments with culturally diverse ethnic groups (Cardemil et al., 2005) and meta-analysis (Sashidharan et al., 2012) examined the overall racial bias with different psychological measuring tools used to identify depression.
According to Walker et al. 2010 depression is often accompanied by the feeling of hopelessness and helplessness.  Recent studies have confirmed that those feelings are a strong indicator that a person may be suffering from depression.  Walker and colleagues, examined the way different cultures and ethnicity have varying patterns of depressive symptoms.  The study reviewed the depressive symptoms and the motivation for living in individuals who were recruited from a college campus in the United States.   They used the Reasons for Living Inventory and Worldview Analysis Scale on a sample of 139 African American and 161 European American participants. Results found that for the group depressive symptoms such as hopelessness and helplessness were on the same level for all participants.  The results suggested that assessments on cultural values and cultural orientation might have important correlation on addressing depressive symptoms.  Ho et al. (2016), echoed the claim by proving that the presence of negative and positive factors are relevant in the conceptualization of depression and depressive symptoms among varying cultural groups.
The social and cultural factor of depression is often overlooked and leads to the misinterpretation of a person’s real problem.  Culture influences our understanding of health and illness, modes of treatment as well as health-seeking behavior such as attitudes to preventative and curative care, attitudes to providers and expectations of the healthcare system  (Gorpalkrishnan, 2014). Therefore, finding adequate treatment options for depression and carefully examining what works and for whom has been vital in the mental health field.  Brown et al. (2007) state that an individual’s social hierarchy has a direct effect on several health-related consequences such as mortality, health care utilization, stress, and support.  Based on these cultural influences, individuals may have poor health, more pressure, and higher mortality rate. Furthermore, studies have proven that cultural variation in emotion influence the way in which individuals cope with mental health stressors (Wong et al. 2010).
According to The World Health Organization, depression is among the leading causes of disability worldwide (Stewart et al., 2004). In addition, depression alone affects a large percentage of college students who are undergoing stressful life events and changes that become overwhelmingly difficult to manage. Trying to become part of a new culture, a new group and being part of a new environment college students are a particular group of people that are facing a stressful time in life and often unable to handle the circumstances, they find themselves getting depressed.  The 2000 United States census reported an increasing change in the American population, with an increase of 24% of the non-White population from 1990 to 2000 (Ying et al., 2004).  To review the evidence around the influence culture has on depression it is imperative to analyze the aspects of culture-specific diagnosis, validity and symptom demonstration. Additionally, it is crucial to review the elements of cultural acculturation, self-efficacy and emotional well-being associated with depression among culturally diverse college students around the United States.
People often mistakenly think that those with mental health issues became comfortable or accept their problem as part of who they are.  However, it is underestimated that different factors may affect the process. One of the critical elements often overlooked is culture.  Talkvosky & Norton (2015) describe culture as a factor shapes a person’s reality, and people from different cultural contexts and traditions have very different experiences. Using the cultural value importance identified by Ho et al. (2016) it was proven that adherence to cultural values is directly related to depressive symptoms.  These experiences shape attitude towards mental health among varying families, countries, ethnicities and individuals.  While these emotions are common among cultural groups, they foster attitudes, stigmas, and beliefs that present challenges in the willingness and readiness a patient may have in addressing their mental health problem.
There is astounding evidence showing that culture affects how health and illness are understood, and how it influences the way mental health is managed.  According to Talkovsky & Norton, P. J. (2015), multicultural awareness is increasing in clinical psychological assessment and practice.  Awareness of cross-cultural issues in psychology has led to many questions about validity and utility of instruments in different ethnic and racial groups (Talkovsky, & Norton, 2015).  Different measuring tools have been used to detect symptoms of depression, anxiety, and other mental illness.  However, the measurements have not been consistent or reliable.  Understanding is the key to developing mental health services that are more responsive to the cultural and social context of racial and ethnic minorities (Riaz et al., 2014).
The majority of researchers have theorized emotion as a psychological construct independent of social and cultural context (Dzokoto, 2010). College Students are a select group who are often affected by depression, as they are going through a time of excitement but also challenges.  As a college student, the experience of leaving loved ones behind, learning independence, meeting new friends, and making new relationships can bring stresses that may cause acculturation stress, self-efficacy issues, and depressive symptoms.  At this time small challenges may seem big obstacles and may create a sense of hopelessness or sadness that doesn’t go away.  Stweart et al. (2004), describes self-efficacy, negative attributions, and hopelessness as concomitants, vulnerability agents, or both in the development of depressive symptoms.
Too often when people from other countries come to the United States, they are left alone to fend for themselves and find comfort on their own. The same is true for many families who arrive at different locations around the world and have to establish new realities and social groups. Santos et al. (2017) found three cultural factors that may impact the psychological health of college students who migrated from their homeland and psychotherapy treatment for depression are self-efficacy, acculturation, and acculturative stress. With the endless amount of subgroups and diversity, culture continues to be important in the clinical setting because it accounts for the different ways people communicate symptoms and which ones they report. Riaz et al. (2014) mention that culture also influences whether an individual will seek treatment, the type of treatment and the coping styles they prefer.
Acculturation Stress
Even with the rapidly growing immigrant population settling in the United States, there remains to be quite limited research and a clear understanding of acculturative processes and their impact on immigrant families. As college students leave their home, they migrate to new places and experience new change as they leave social networks behind. This transition makes some feeling a sense of loss, loneliness, isolation or dislocation which lead to processes of acculturation. According to (Carrera & Wei, 2014) acculturation refers to the change or modification process people make to their behavior to adjust to another culture.  Acculturation is a factor related to depression for people of other cultures.  Acculturation has often been used to account for psychosocial changes and health outcomes and has been used to explain health disparities among ethnic groups (Carrera & Wei, 2014).
Culture refers to the symbolic and learned aspects of human groups or societies, including language, beliefs, attitudes, values, norms, and behaviors (Sashidharan et al. 2012).  As people come or go to different places in the world, they have to use different approaches to adapt to different cultures, which is often time very different than the culture they are accustomed to. While there is no right or wrong way of adjusting to a new culture, the way in which this process happens affects the levels of depression symptoms they experience.  Conversely, studies have also shown an individual’s adherence to cultural values was not significantly related to depressive symptoms (Wong et al. 2010), acculturation (Carrera et al. 2014), and psychological distress (Wang et al., 2016).
The growing interest in studying the correlation between cultural values and effects on mental health, moved Wong et al. (2012) to review the way in college students cultural backgrounds followed them while integrated within a prominent culture, and how acculturation stress developed and played a role in the development of depression.  Wong and colleagues piloted a hidden profile analysis of participants, using the five subscales of the Asian American Values Scale-Multidimensional (AAVS-M) in a sample of  214 college students. The participants came from Southwestern urban areas and were all born in the United States but they all had varying cultural backgrounds. To measure the adherence of the participant to their cultural values an AAVS-M was used and to document depressive symptoms the Beck Depression Inventory (BDI) was used.  As expected the bivariate level showed that only values were directly related to BDI in the overall sample.
Self-efficacy
Self-efficacy is defined as the confidence someone has on themselves of integrating within a social setting.  Stewart et al. (2004), document how that levels of self-efficacy contributed to variance in depressive symptoms.  Stewart and colleges analyzed the relationship between feelings of self-efficacy and the manifestation of feelings of depression among a culturally diverse group.  The study focused on the relationship between depressive symptoms and cognition within a large group of high school students between the ages of 14 and 18 in Asia and the United States.  The measure used to gauge depressive symptoms was the Asian version of the Beck Depression Inventory and the BDI-II in the United States.  The results revealed a significant correlation between self-efficacy and depressive symptoms among all participants regardless of location.  However, participants in Asia demonstrated higher depression feelings such as hopelessness than the United States participants. The findings were consistent showing that symptoms of depression were higher in Hong Kong youths which included the feeling of helplessness.   These findings also confirmed that an individual’s culture was closely related to high levels of depressive symptoms.
Acculturative Family Distancing
In the past decade, numerous research on acculturation process has shown the relationship between depression and acculturative stress (Carrera et al. 2014), emotional reactivity (Chentsova-Dutton et al., 2007), and depressive symptoms (Castillo et al., 2015).  Furthermore, the bulk of research that has looked at the impact of acculturation process has focused on the United States and have included Asian and Latino population. Although multicultural awareness is increasing in clinical psychological assessment and practice (Talkovsky et al., 2015) most multicultural research has not taken into account the relationship between acculturative family distancing (AFD) and bicultural competence (BD) and the development of depression using structural equation modeling Dzokoto (2010).
Acculturative Family Distancing (AFD), is the distancing that occurs between immigrant parents and children that is a result of immigration, cultural differences, and differing rates of acculturation (Hwang, 2006).  Acculturative Family Distancing is more relating to, and problem-focused creation of the acculturation gap and is thought to increase depression through family struggles.  Different studies and research result show acculturation stress which leads to acculturation family distancing increase depression through family conflict. Torres (2010),  investigated how acculturation, acculturation family distancing, and coping are good indicators of the presence of depression within a specific ethnic group.  The study included volunteers of varying age group from local communities who had expressed feelings of depression.  The Multidimensional Acculturative Stress Inventory (MASI) used to measure stress, the Behavioral Attributes of Psychosocial Competence Condensed form and (BAPC – C) to evaluate coping mechanism (Torres, 2010).  The study results highlighted the importance of the environment, interaction and culture as contributions to mental health among the community.  Overall, the study quantified the concept that cultural pressures and demands increase the chances of experiencing mental health problems.
Similarly, Dzokoto (2010), examined the relationship between acculturative family distancing (AFD) and bicultural competence (BD) and the development of depression using structural equation modeling.  241 college students from several Midwestern universities in the United States completed an online survey identifying them as Hispanic.  Precautions were taken by including validity check items used to prevent responses that were not accurate.  The results revealed that bicultural competence (BC) affirmed the relationship found between acculturative family distancing and depression.  These results also confirmed the positive correlation between having higher levels of AFD and lower levels of BC and the appearance of depression.  It confirmed that if bicultural competence is improved for those having higher AFD depression can be reduced.
Experimental support for the relationship between acculturation and mental health suggests that it is important to examine acculturation in relation to treatment options. The process of acculturation often results in changes in the health behavior of international students.  One example as stated in Santos et al., (2017), the nature of the acculturative changes experienced by a Latino individual once in the United States may impact the degree of fit with mental health services available and thereby affect retention. The process can lead to acculturation stress which can bring many undesirable symptoms such as sadness, loneliness, sleep problems, and depression.
Presently conceptualizations and measures of acculturation and acculturative stress reflect an understanding that these concepts are complicated and multidimensional, and involve and ongoing processes of review. Whereas acculturation was previously seen as a process of change that occurred within the dominant culture, it is now seen as a process that can occur within more than one culture simultaneously, such as within a culture of origin and a host culture (Dzokoto, 2010). For instance, a college student becomes acculturated to the dominant culture, she or he may also undergo the process of acculturating to the culture of origin. Moreover, early work on acculturation focused on examining change within the language domain, specifically use, proficiency, and preference (Zea, Asner-Self, Birman, & Buki, 2003). However, the domains of values, attitudes, and beliefs have also been said to reflect acculturative changes and important areas to examine to more fully understand acculturation processes (Rodriguez, Myers, Mira, Flores, & Garcia-Hernandez, 2002).
Kanazawa et al. (2007) reviewed the variation of depressive symptoms in a college community.  Kanazawa and colleagues examined the difference in symptoms experienced by a multicultural group of participants with a previous history of depression.  A local Personality and Health Group provided data used for the study, which included information about the participants’ mental health and personality history.  Depression symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D), commonly used with community samples (Kanazawa et al., 2007).   The results echoed those of previous studies which showed consistency in the differences of multicultural variation of depressive symptoms and internal conflicts.
The validity reliability of increasing awareness of cross-cultural issues in psychology has led many to question the validity and utility of instruments in non-majority ethnic and racial groups (Talkovsky et al. 2015).   According to Cardemil et al., (2005), culturally appropriate programs that provide assessable and effective treatment for the minority population are an important factor to consider when working with a diverse group.  Culturally appropriate prevention and treatment programs offer an alternative, accessible and effective mental health services for those who have specific needs.  Cardemil et al. (2005), introduced a program designed for families of a Latin community to help them assess the cultural factors that influenced depression with the group.  Cardemil and colleagues developed the Family Coping Skills Program (FCSP) to help the community have a culturally appropriate depression prevention treatment assessable to them.  Results indicated no major correlation between the varying cultural background and depression symptoms.  However, the way in which participants coped with these feelings and searched for treatment options was influenced by their cultural background.
In the same way, Chentsova-Dutton et al. (2007), documents the evidence found in an emotional reaction in people experiencing depression.  The study made a comparison of depressed and non-depressed cross-cultural group and their emotional experiences, reactions, and behaviors.  The participants were shown several movies from a different genre.  While watching the movies, researchers used Gross and Levenson’s Emotional Expressive Behavior Coding System (EEB) to record facial expressions.  The results did not show any differences in facial expression during the movies.  Researchers have suggested that depression is prevalent in all ethnic groups; thus, it is important that these groups are included when examining interventions designed to alleviate depression (Iwata & Buka, 2002).
Culturally Sensitive Treatments and Measuring Tools
As depression continue to be one of the most prevailing and damaging mental disorder, and mental health professionals aim to provide culturally appropriate treatment to all patients, it is important to consider the relevance of cultural sensitive treatments for the entire population.  According to Kalibatseva et al. (2014)  most of the evidence-based treatments (EBTs) in the United States are designed for use with Western cultures, researchers must focus on integrating treatments that are equally effective for other cultures (e.g minorities or people from other countries).  Most of the popular psychological measures used to test depression were developed for the primary use of Western cultures (Sashidharan et al., 2012).
Despite the great validity properties and calibration of the BDI-II on various populations, ethnic minorities have not been properly represented or adequately studied.  Furthermore, these tests were not modified when used in different ethnicity or those having different cultural backgrounds, creating a racial and cultural bias.  Sashidharan et al. (2012) examined the manifestation of depression as detected through a sample of 977 undergraduate college students recruited from Midwestern University with data collected over an academic year.  A two-step hierarchical multiple regression analysis was used to detect racial bias within the test measure.  The comparison was made using the Beck Depression Inventory (BDI-II) and the Center for Epidemiologic Studies Depression Scale (CES-D) which are both frequently in a multicultural population.
In their study, Sashidharan et al. were not able to show any apparent proof of racial bias when using the BDI-II against the Standardized measure for African Americans.  Results delivered a valid measure of depression for the participants regardless of their sociocultural factors.  The average results were calculated based on gender and ethnicity using ANOVA which confirmed no significant difference between the two measures.  In support of the idea, Santos et al. (2017), compared the effectiveness of treatment approaches such as Behavioral Activation for Latinos(BAL) and Treatment-as-usual (TAU) and their capability of keeping patients involved in treatment.
Santos et al. used Spanish-speaking Latinos who were in need and looking for treatments at local health centers within the community.  The study used a randomized sample of Latinos volunteers between the ages of  18 and 65 who had not been previously hospitalized and who were classified as depressed.  To measure the relationship between treatment condition and sessions attended, Hierarchical multiple regression analyses were performed.  Results suggest that acculturation bias may have a major role in the type of treatment sought and total sessions participants attended.  Total sessions participant attended had a direct correlation to the level of pressure against acculturation (PAA) the person had. This result proposes that PAA can be a challenge for retention when using treatment-as-usual (TAU).
Leu et al. (2011), talks about associations between negative, and emotions and the influence culture has on positive emotions and depression.  600 European migrant, immigrant, and Asian American college students were surveyed to compare positive emotions to depression symptoms. Participants completed a survey on measures on perceived stress, emotions, frequency of depressive symptoms. Different measures were used such as MacArthur Scale of Subjective Social Status and Perceived Stress Scale.   Results using one-way analyses of variance (ANOVAs) showed that immigrant Asians reported more depression than European American.  The comparison showed a valid relationship between negative emotions and depression for all groups.  Evidence was also found on acculturation and the influence people place on positive emotions in depression.
Wong et al. (2010), examined the loyalty to cultural values, attributions, and solution to depression.  There were a total of 238 Asian American participants from all over the United States.  The study was given online via a computer program on the internet. The procedure included questionnaires and vignette sent to the participant using Coping Strategies Inventory (CSI) as a measure of a hierarchical structure of coping and Attribution of Problem Cause and Solution Scale (APCSS) a 7-point scale to measure responsibility attributions.  Independent sample t-test was used to examine differences in participants sex, generation, and participation differences among the measures used.  Results show that culture does have an important and vital role in the way individuals view, cope and search for a treatment for depression.  Participants who strongly have strong cultural values used disconnection as their coping way to depression.
Neto (2010), This article showed the investigation the authors performed on predicting mental health problems on immigrant adolescents. A sample of 360 high school students who returned from France, between ages 16 and 18 and attending Portuguese public schools was used.  Reported mental health levels were similar for both teenage groups, ones from immigrant families and those who never migrated.  Younger Females showed higher mental health problems than Older Males.  Although acculturation variables were assumed, adaptation variables still contributed to mental health outcomes. To measure the adaptation and mental health across cultures, an international group of scholars was used.  The study results showed that the degree of mental health problems among returned adolescents, and the factors that might predict the level of mental health problems among them were all consistent with the level of acculturation.
Rosselló et al. (2008),  shows the authors comparing results of individual to group Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for the treatment depression among multi-cultural groups of teenagers. Participants of the study were in grades 6th to 12th and not on any medication for mental health issues. All participants received posttreatment and pretreatment. To analyze the random process of pre and post treatment status of participants, a two-way (ANOVA) was used. The authors used descriptive statistics to identify were used considering treatment condition and format to identify deviations on the distributions scores at pre and post-treatment.  The outcome of the study showed that cognitive behavioral treatment (CBT) showed bigger decreases in depressive symptoms as measured by the CDI in comparison to IPT. CBT also showed a significant reduction in internalizing and externalizing behaviors. Results also showed no difference in outcome when using individual or group setting.
Talkovsky (2015), The authors examined and compared the metric effects of The Mood and Anxiety Symptom Questionnaire (MASQ) which is an extensively used measure of anxious and depressive symptoms in different ethnic and racial groups. Participants completed demographics form and self-report questionnaires. All who completed the self-report questionnaires were included.  Data were analyzed using the MASQ, BAI, BDI, and Positive and Negative Affect Schedule (PANAS).   Results suggest that the validity of MASQ were similar across all groups.  General Distress and Anxious Arousal factor showed variances of loading.
Hayes et al. (2015), discusses the authors view on the importance in racial, ethnic minority clients (REM) and the requirements of culturally competent psychotherapy for this group.  The authors investigated thirty-six therapists and 228 patients who were treated at a training clinic at a local university.  The purpose was to find out the varying effectiveness of therapists and client ethnicity.  Participants completed the Outcome Questionnaire-45 (OQ-45) before the beginning of each therapeutic session.  Results revealed the no differences in outcome for REM and non-REM clients.  It was also evidenced that there are different levels of effectiveness and the variability was due to client REM status.  Overall outcome presented varying levels of therapist effectiveness with REM clients.
Brown et al. (2007), examined of the paths of depressive symptoms in multicultural groups across the nation. Participants were self-identified as White, Black, Hispanic and Asian. There was race-ethnic variation among the group of females and males and different race-ethnic groups.   Results revealed a significant relationship between stressors and depressive symptoms in all study participants.  Findings also showed race and ethnicity as a vital factor to consider for depression symptom path throughout a lifespan. Neither background characteristics nor social support showed improving the gap.  However, social support represents a possible potential bridge for the race-ethnic differences.
Depression is not only a problem that affects White American problem, but it also affects other ethnic groups including Latinos, Asians and African American’s.  Iwamoto et al. (2010) investigated direct and curbed properties of racial and ethnic identity, values, and race-related stress on positive mental comfort amongst a culturally diverse sample of international college students.  The study built on previous research addressing the relationship between racial and cultural identity, values, stress and mental well-being.  The study included 402 culturally diverse college students, all having some Asian background.  The survey used included questions relating to cultural background, ethnicity, and values.  Results revealed that levels of cultural rank, involvement, conflict, values, and identity are forecasters of well-being.  While no significant relationship was found between conformity and dissonance.  The findings underline the significance of how cultural uniqueness, morals, and ethnic identity jointly and uniquely explain and moderate the effects of race-related stress on positive well-being.
Ellis et al. (2015) review the health behaviors associated with psychological distress and the relationship between negative affect and behaviors by race and ethnicity.  The authors focused on examining how feelings of depression and anxiety are different based on race and cultural background.  Data analysis was gathered from the Health Information National Trends Survey 4 Cycle 1 (HINTS). Participants self-identified as non-Hispanic White, non-Hispanic Black, or Hispanic completed a survey available in English and Spanish. To measure Psychological distress a 4-item Patient Health Questionnaire (PHQ-4) was used to determine symptoms of depression and anxiety. Health behaviors were categorized based on the participants smoking history.  Each was categorized either as smokers or nonsmokers.
The result showed greater depression symptoms associated with White adults and greater odds of smoking.  While Hispanics showed depression symptoms significant to smoking and negative behaviors.  Interchangeably, cultural factors influence the relation feelings of depression to health behaviors.  Evidence proves coping strategies differ among culture and that it influences in quality of life.  Overall findings show symptoms of depression and behavior is distinctive to White, but not Blacks and mixed for Hispanics. This is central to understanding mechanisms that affect health behaviors among culturally diverse individuals.
Soto et.. al. (2011), authors aimed to discover the relationship between health suppression is reliant on cultural context, due to the different cultural norms around the value of suppressing display of emotion. 71 college students were recruited for the study from United States University and 100 participants from Hong Kong Chinese from two universities from Hong Kong.  Participants were able to complete an online survey and consent form, followed by a debriefing statement.  Measures used included Emotion Regulation Questionnaire (ERQ), Satisfaction With Life Scale (SWLS) and Center for Epidemiologic Studies Depression Scale (CES–D).  Two hierarchical regressions were performed to test the relationship between depressed mood and life satisfaction.  Results found a strong relationship between negative memories, suppression, and emotions.  Unlike East Asian cultures, European Americans emotional limitation is not expressed emotionally.  These findings highlight the significance of context in understanding the suppression–health relationship.
Castillo et al. (2015), examined the relationship between variables in acculturation and depressive symptoms among Latino college students as well as the extent to which acculturation bring about the association. Participants included 758 Latina and 264 Latino college students from different colleges in the United States.  Participants were given different measures to test for acculturation, stress, and identity.  For acculturation, the Stephenson Multigroup Acculturation Scale (SMAS) was used, for acculturative stress the Multidimensional Acculturative Stress Inventory (MASI) and to identify depression symptoms the Center for Epidemiologic Studies Depression Scale (CES-D).
Results showed that the relationship between acculturation and depressive symptoms are consistent and significant with study variables.  It was evidenced that stronger depressive symptoms in relation to culture acquisition, retention, and acculturation for men than for women.  This is consistent with the fact that men feel more stressed being bicultural.
Carrera & Wei (2014), evidence what most all research theorized, emotion as a psychological construct independent of social and cultural context. In a two study investigation using Ghanaian and Euro-American college students, the authors in this study set out to demonstrate the way effective experiences were unique in a multicultural setting.  70 West African and 100 American undergraduate students were recruited from a social science department in a University. Respondents completed a Body Awareness Questionnaire, containing questions regarding body image and emotion.  Measures were compared using Attention to Emotion subscale from the Trait Meta-Mood Scale (TMMS), Somatization scale of the Symptom Checklist 90-Revised (SCL-90-R) both which have been previously translated into at least 26 different languages.  Finally, Positive and Negative Affect Scale(PANAS-X) was used to check the negative effect on somatic and emotional focus. Results showed that unlike American participants culturally diverse individuals were more aware of their body than their emotions.  Both studies provided quantitative evidence that emotion differences across cultures psychologization in mental health.
Due to the length of most measuring instruments for mental health issues and, the authors conducted two studies to measure mental strengths and resilience of individuals with mental health issues. The authors created a short, brief inventory to assess three strengths, temperance, intellectual, and interpersonal.  The studies were conducted in Hong Kong. Frist study included 149 participants from a psychiatric rehab center.  These participants help establish the factor structure and validity of the BSS-12 measure. The second study included 203 college students from China and was used to examine the factorial variance of the BSS-12 in a different culture and population.  The results showed consistency in the use of BSS-12 as a complement to existing longer inventories.  It also showed that the briefness of the BSS-12 inventory has better use and is more applicable when used for initial clinical screening and to keep track of changes in strength throughout the treatment process.
Wang et al. (2016), The authors examined the Chinese version of the Anxiety Stress Scales (DASS-21) by administering the test to two different set of participants at different times. The first study included 1,815 Chinese college students who were tested within a classroom setting.  Most participants were Chinese, and the remaining were from 17 different ethnicities. Self-report questionnaires and demographics forms were completed and returned by participants.  Responses were analyzed against DASS-21, BDI and State-Trait Anxiety Inventory. For the second study 166 participants having schizophrenia were recruited.
In both studies, the authors assessed the psychometric properties of DASS-21 and explored the clinical usefulness of the measure on patients with mental health problems.  Results for both studies showed evidence that the use of DASS-21 supports the cross-culturally validity in the clinical use and self-report measure for the screening of general distress as well as negative emotion among individuals with different cultural background.
LITERATURE REVIEW METHODOLOGY
Evidence-based peer-reviewed articles researching cultural effects on depression and culturally appropriate measures and treatment options were found using the ProQuest database.  Keywords and relevant terms included cross-cultural differences, acculturation, depression, racial and ethnic differences in combination with ethnic values, coping behavior, culturally sensitive, cognitive process, social cultural factors, symptoms and ethnic identity.  In addition, studies were limited to research conducted from 2004 through 2017 resulting in a plethora of information and data available to substantiate the cultural factors that influence mental health and depression.
CONCLUSION
The purpose of this review was to view the effects of culture on depression.  It is clear from the research reviewed that depression is one of the most debilitating disorders and affects people worldwide.  The
 



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